Activist framing of abortion and use for policy change in Peru.

Identifying how activists frame the topic of abortion is key to unpacking their understanding of "abortion" in Peru. It is important to explore how and why certain frames are privileged in attempts to shift policy and social norms. In 2016, the authors conducted qualitative interviews with 10 activists in Lima, Peru to develop a deep understanding of these issues. Activists worked through different approaches and lenses, including law, medicine, sociology, psychiatry, journalism, non-governmental organisational management, LGBTQ rights, and indigenous rights. Four common frames emerged through the analysis and those frames shifted based on whether activists were speaking to the general public or to policymakers. Understanding Peru's activist framing of abortion can contribute to a deeper analysis of regional and global movements to legalise abortion, which also take into account local specificities.

Introduction

In Peru, abortion is criminalised. Exceptions to the law include situations when pregnancy threatens the life or health of a pregnant woman. This law was established in the 1924 Peruvian Penal Code and has not been expanded to include any other indications since that time.[1] While activists have made multiple attempts to decriminalise abortion in cases of rape, incest, and foetal abnormalities, none of these efforts have yielded policy changes. One campaign in particular, Déjala Decidir (Let Her Decide), gathered 60,000 signatures in 2015 for a bill to decriminalise abortion in cases of rape, but it was rejected in committee before Congress could vote on it.[2] Peru has the sixth highest maternal mortality ratio of all South American countries,[3] and unsafe abortion is among the top five causes of maternal death in the country.[4] Peruvian women who live in poverty and in rural areas continue to experience the highest unmet need for contraception, highest fertility rate, and highest rates of complications from unsafe abortions.[1,5-7]

Given the Peruvian cultural context and the social and political trends in sexual and reproductive health over time,[1,8] identifying how activists frame the topic of abortion is key to unpacking their understanding of “abortion” in Peru, as well as how and why they privilege certain frames in an attempt to shift policy and social norms.

Framing is a practice by which activists direct the focus of discussions or promotion of an issue in order to change or supplement understanding of the issue, mobilise support, and provide guidance for actions.[9,10] Activists use certain frames and avoid others, based on the social, political, and cultural environments in which they work, knowing that the same frames used in different time periods, countries, or populations will not resonate the same way.[11] Framing is used both to engender support in the general population and to influence policymakers to change policy.[12] Framing is thus changed, not only based on overall context, but also on who the activists’ audience or public is.

Particular ways of framing abortion in Latin America have been documented in previous work. Gianella (2017) analysed abortion framing in op-ed articles in two Peruvian national newspapers, focusing on opinions for, or against, abortion and emergency contraception between 1990 and 2015.[13] The study focused on legal mobilisation, or “strategies that use rights and the law as central tools for advancing a contested political goal.” Three major frames emerged from the analysis: the right to life, “(un)domatization of abortion legal mobilization,”[13] and the relationship between judicial, legislative, and societal legal mobilisation. In Uruguay, framing abortion as an issue of reproductive health was successful as a legislative strategy[14] and first trimester abortion was legalised in 2012.[15]

Methods

The research team aimed to include participants from a range of professional and activist backgrounds to ensure that different perspectives to understand abortion were included. During June and July of 2016, the first author lived in Lima, Peru and contacted potential participants through phone or email. An initial list of 10 activists was identified by the third author, who is a senior figure in a Peruvian national organisation dedicated to promoting sexual and reproductive rights. This list was generated based on the named activists’ knowledge of, and proximity to, abortion in their professions and social advocacy. Every participant was asked to suggest other activists to contact for participation in the study. Sixteen participants were identified by the third author or participants, of whom eight completed an interview, six were unreachable for an interview, and two responded with interest but were unable to complete an interview. Two participants were contacted by the first author, independent of suggestions from the third author or other participants. This was done to ensure that not all respondents were part of the same professional/activist network. The first author conducted online research to find two participants who would be willing to be interviewed for two additional perspectives (faith-based and indigenous) that were not included in the initial sample, and we believed they were important in the sociopolitical climate of Peru. Ultimately, just over half (55%) of all persons (n = 18) contacted participated in an interview (n = 10). The 10 interviews were conducted by the first author, and each lasted 45–60 minutes. Nine of these interviews were in Spanish and one was in English.

For a participant to be considered for an interview, we ensured that the person was personally and/or professionally engaged with abortion in Peru in some capacity. For example, some participants performed abortions as OB/GYNs, some worked in non-profit organisations that advocated for abortion rights, and some conducted research on abortion. The professions, backgrounds, and perspectives represented by the participants include non-profit organisations, health/medicine, sociology, psychology, legal counsel, theology, LGBTQ rights, indigenous rights, and journalism. Some participants’ profiles were a combination of these backgrounds.

Before beginning each face-to-face interview, a consent script was read to the participant and oral consent was garnered. Transcriptions of the interviews were done through an agency based in the United States. Initial codes were developed, based on the themes of the interview questions, and other codes emerged from the coding process itself. The first author coded each transcript, with regular reviews made by the second author and adjustments made according to discussions between the first and second authors. In this article, we focus on a subset of those codes, guided by two overarching interview questions: “How significant a problem do you think unsafe abortion is in Peru?” and “When talking to stakeholders on abortion policy, is there a narrative you use most commonly to frame the conversation?” The answers to the first question reflected how participants generally frame abortion in Peru, and the answers to the second shifted focus to how they specifically frame abortion with key influencers of abortion policy. Quotations from participants were translated to English by the first author and the names of participants were replaced with pseudonyms to ensure anonymity. This study was reviewed by the third author in Peru and submitted to the Institutional Review Board at the University of South Carolina where it was approved.

Results

Four dominant frames emerged and were used by at least half of all those interviewed. The four frames were: Autonomy, Maternal Morbidity and Mortality, Economic, and Pragmatism. In this section, we present a description of the frames and how they were used for two different audiences: a general audience (e.g. friends, family, co-workers) and a policymaker audience (e.g. congress members, heads of ministries). Table 1 provides a summary of the findings.

Table 1.

How the topic of abortion is framed by activists in Peru

Frame	Definition	# participants who used frame with each audience
		General audience	Policymaker audience
Autonomy	A woman should be able to make decisions about her own body, including the decision to have an abortion	8	1
Maternal mortality and morbidity	Unsafe abortions are a major cause of maternal morbidity and mortality	8	3
Economic	Women of lower economic resources are most affected by complications with unsafe abortions	6	0
Pragmatism	Women will have abortions whether or not it is legal and restricting the abortion law does not result in fewer abortions	4	4

Autonomy

Many of the activists spoke to a general audience about how the abortion law limited a woman's right to make decisions about her body and future. One activist believed the restrictive abortion law was not only about diminishing a woman's bodily autonomy, but that the law treated woman's bodies and decisions as criminal. She worried less about the judicial consequences of abortion and more about how the law positions women as criminals because of their potential to become pregnant. Only one activist used the Autonomy frame directed at a policymaker audience, bringing in the Christian notion of free will:

“I believe that a woman has the right to decide, ‘I don't want this pregnancy’, for whatever reasons she has. She has that right, but she is confronted with a law that doesn't allow this right. The law is very restrictive.” (Gabriel, OB/GYN)

“We should give women the opportunity under whatever technical guide to have children that they desire. Do you understand? Rather, it's not just a position on abortion; it's everything that is the rights of women.” (Isandro, OB/GYN)

“It's recognizing that women do not have the power to make decisions, especially about reproduction, and so there are others that make the decision for her.” (Raquel, Midwife)

“I’d say, well the problem with criminalizing abortion is not the fact – well yes. It is a problem, but it is not in the fact that they are throwing women in jail … I would say, initially, the consequences are brought because the body and the decisions of women are criminalized.” (Juanita, Legal Advisor)

“Well, in the first place, a woman is the subject – this deals with the defense of life, of her life – and of choice or the right to freely choose. I believe that if – if we believe in God, right? That he has created us as free subjects, responsible, then it should not be the decision of the masculine authorities but of the woman herself as subject to decide about her body and how to care for it. She is – so it deals with the defense of the life of the woman.” (Marisol, Theologist)

Maternal Mortality and Morbidity

Another frame used equally often with general audiences was the framing of unsafe abortion as a major cause of death and disability. Activists made clear connections between the law and women's probability of having an unsafe instead of a safe abortion. Activists qualified this framing by pointing out the fact that certain groups of women are more at risk of death and disability, often combining it with an Economic frame. The Maternal Mortality and Morbidity frame was also used by three activists for policy-maker audiences, addressing their responsibility for preventing deaths from unsafe abortion. They liken abortion to other diseases prevalent in Peru and attempt to strip morality from the issue by describing it as a public health issue. One activist, an OB/GYN, shared a story of a debate over abortion in the legislature he attended in which he and another medical expert were on opposing sides of abortion legalisation. The doctor opposed to abortion brought in a young girl who had been diagnosed as having physical deformities while in the womb. She stated that she was thankful her parents did not abort her when her mother was pregnant despite being aware of her condition. The activist interviewed for this study described her testimony as very moving and painful. To demonstrate why he believed abortion should still be legal, he told the committee: However, he later admitted to the interviewer that this particular story of the woman dying on his operating table had not happened to him, it has happened to other doctors, family members, and friends of women who have died from an unsafe abortion. He presented this story of a woman dying as the most powerful argument to policymakers as a rebuttal to the young girl's anti-abortion testimony.

“Women are using catheters, they’re doing it with – with some type of abortive herbs, abortive pills, et cetera, they do it like that. And when a woman starts to bleed a lot, they send her to the hospital, right? But before, because she's afraid, because in the hospital they’ll take her and detain her … and out of fear, many of those women die in those cases.” (Olenka, Indigenous Rights Activist)

“What is this law for? It's just so that women are confronted with unsafe abortion. So that they put themselves at risk of dying. We are talking about dying. And if they don't die, they can also be hurt for the rest of their life.” (Gabriel, OB/GYN)

“It's unavoidable. It's a very uncomfortable topic for many but it's a necessary topic, urgent, because it causes deaths, because it causes morbidities, and because the most affected are the poorest women, rural women, youngest women.” (Gloria, Sociologist)

“The State has to be conscious that, like how dengue kills, zika kills and chikungunya too, abortion kills. And it kills women of reproductive age and young women basically.” (Eymi, Psychotherapist)

“If you want to convince a majority of people … it's much more direct to say, ‘Look, there are so many women in the morgue for these reasons, and the ones dying are the ones with fewer possibilities of accessing services, so, although you don't want it and it seems immoral to you, it is a cause of death’.” (Gloria, Sociologist)

“So I said that I was moved to see her, I said, that I had – had suffered a lot with that. But I also had a case to present, who lamentably couldn't be there, because she had died on the table with her intestines outside her in a poorly done procedure. That she died from a septic abortion and she died and she was telling us she didn't want to die, she wanted to live.” (Isandro, OB/GYN)

Economic

The Economic frame focused on how a restrictive abortion law created an inequity in care between poor and non-poor women, wherein women with resources are still able to access safe abortions while low income women are faced with unsafe options. The Economic frame was not used by activists for policymaker audiences.

“Well, I think to have a safe abortion is costly. Most women can't afford it. Most women don't have the opportunity to go to a clinic or to go to a hospital or a known doctor or someone they can meet and arrange for them a safe abortion. It can cost up to 2,000 sols [US$600]. Most women don't have 2,000 sols to go for a safe abortion so they have together how much money they can get and go to an unsafe clinic or go to a drug store.” (Luz, LGBTQ activist)

“Now we are in a situation where those who have the least money are the ones with the most risk.” (Lora, Journalist)

“People come to Lima, and they see offers that are totally unsafe – or ineffective. The other option is to have a large amount of money to go to a professional – something that doesn't happen often.” (Eymi, Psychotherapist)

Pragmatism

The Pragmatism frame can be described at “either at the individual level (as a woman's last resort) or at the collective level (with the notion that abortion happens, and that state and society need to come to terms with it   …)”.[16]

The frame emerged in interviews with activists at both the individual and collective levels. At the collective level, activists claimed that although the law is in place theoretically to reduce the number of abortions, there are still many abortions occurring in Peru. This occurred through framing with general audiences. The Pragmatism frame at the collective level was also used for policymaker audiences. Similar to other frames, an activist positioned abortion as equivalent to other major diseases: Activists also used the individual level of the Pragmatism frame with general audiences, speaking very bluntly that women turn to abortion not because it is something they want, but something they have to do. An activist also used this frame with a policymaker audience, echoing that women feel they have no other choice than to abort and adding that policymakers can ensure these women who are making difficult decisions are not also experiencing threats to their maternal health or bodily autonomy.

“The law is very restrictive. So a woman has to do it clandestinely, she has to stay hidden to look for how to do what she needs. Despite that, it's very frequent. There are 350,000 abortions. So this law shouldn't exist. And how many women are punished for abortion? Very few. So, what is this law for?” (Gabriel, OB/GYN)

“The assumption of these laws is that there should not be abortions. But the reality of public health shows that it is a reality for thousands of women.” (Gloria, Sociologist).

“What I always say is that even when – if – all women had access to contraception, there will always be some necessity for some women to interrupt a pregnancy. That is to say, abortion is not something that you can eradicate like malaria or zika. No, there will always be a possibility that someone needs an abortion.” (Eymi, Psychotherapist)

“A woman doesn't want an abortion. No one wants to have an abortion. You [the interviewer] are a woman. What woman wants an abortion? No one. No one.” (Gabriel, OB/GYN)

“I believe no one is looking for an unsafe abortion. What happens is they have no other option. So, we could say, what leads a woman to seek an abortion, safe and legal or illegal, is primarily because it is a necessity.” (Raquel, Midwife)

“This is why I believe that the people we work with – that they understand that a woman doesn't become pregnant so she can have an abortion, but that there are circumstances that force a woman to have to make this decision that is painful for everyone. That they understand that this should be done in a legal framework that gives them the safety of not dying or suffering from illness. So we have to keep working on this because firstly, at some point as a modern country, we have to have a country that respects the rights of women to decide.” (Isandro, OB/GYN)

Frame use between audiences

Activists used more frames with more frequency with general audiences than with policymaker audiences. Many noted that they did try to change the framing of their conversations when they spoke with policymakers, but some were unable to present the specific framing they used. When activists were asked, “Have you noticed changes in your conversations depending on who you are talking to?”, generally they responded affirmatively. Others noted that speaking to policymakers was far different from speaking with a general audience because policymakers were less open to hearing arguments about the liberalisation of abortion. Overall, activists used few frames with policymakers, and of the frames that were used for both audiences, the frames were used in fewer instances with policymakers.

“Of course, I think when you are discussing these approaches, you have to place certain arguments that can better guide us towards issues that we can agree with from different positions.” (Raquel, Midwife)

“Now, there is greater opportunity to talk. I think that, at the level of the media, of the population – people are more flexible about their opinions. The young people are more – they say ‘I respect that’. Men respect women's decision more, right? But at the level of the authorities! That is where there is a – and it doesn't matter if the authority is 30 years old. When you’re in the public eye, everything changes. If you were a defender of a cause, then you backtrack completely because you’re in the public eye. So, they don't want to fight with anyone.” (Eymi, Psychotherapist)

“The public opinion changes enough, so the president and the congressmen and the constitutional court don't want to seem unpopular – at least fight, right? Because as I say, as long as it is not considered profitable politically, no one eats the enchilada.” (Gloria, Sociologist)

Frame avoidance

When asked if there were any frames activists avoided using, the only one that was mentioned multiple times was the concept of the foetus and the “pro-life” movement. Several activists preferred not to engage in this discourse because they know that it is difficult to talk about whether a foetus has rights in their country. The topic made them uncomfortable and they believed trying to argue that a foetus does not have a “right to life” would not be effective in their messaging for abortion.

“I don't think they have the same worth. So I wouldn't be able to say – even though it's the correct argument, it would cost me a lot to say something about the conflict of rights, because of course the fetus has almost the same worth as the life of the mother. So to use this type of argument is conflicting to me not only because I don't necessarily believe it but also it is dangerous – how do I get out of that answer in a legal analysis? In a legal analysis, I cannot do that with the media. So, who wins a debate? Who wins? Whoever communicates better.” (Juanita, Legal Advisor)

Discussion

The four frames identified in our study were also found in the list of frames generated by Sutton and Borland in their study on the framing of reproductive rights in the 1986–2007 Encuentros Nacionales de Mujeres (National Women's Meetings) in Argentina.[16] The study analysed concluding summaries of the Encuentros in Argentina, which were annual meetings of many Argentine women dedicated to discussing activism around issues affecting women in Argentina, including abortion and reproductive rights. From these Encuentros, there were 10 frames identified, and the frames most comparable to those identified in this study were Public Health (Maternal Mortality and Morbidity), Economic/Social Justice (Economic), Body (Autonomy), and Pragmatism. Sutton and Borland's study is particularly salient to the results of this current study because many of the same frames used in the Encuentros were also used by participants in Peru.

The activists in this study did not explicitly identify frames that they considered more effective than others, only those which they preferred to either use or not use. This lack of identification of effective frames may be related to the fact that Peru has not experienced a legislative success for abortion rights since 1991 when the law was amended to slightly reduce the sentence for those having an abortion.[17] Peru's abortion law has largely remained unchanged since 1924, leading to difficulties in identification of effective strategies for change.

While certain frames were not explicitly identified as being more effective, activists did seem to choose or avoid frames consistent with frames also used by current or former policymakers as iterated in the study on legal mobilisation in Peruvian newspapers.[13] In Gianella's analysis, she presents examples of op-eds written by four current or former congress people and ministers on the subject of abortion in Peru. Of these four, two present arguments in opposition of abortion liberalisation and two in support. Both cases of opposition opinions reference “killing innocent people,” referring to the “pro-life” ideology of life beginning at conception. This may influence why activists in our study explicitly avoided presenting abortion in terms of “pro-life” framing.

The two op-eds in support of abortion liberalisation both reference abortion as an issue of protecting women's life and health.[13] In the same way, the activists in our study used a Maternal Mortality and Morbidity frame several times with policymaker audiences. The idea that some policymakers are currently using that frame in their discussions signifies that discussing abortion through this lens could resonate with other policymakers.

Though several activists used the Economic frame with general audiences, none used it for policymaker audiences. When activists spoke about policymakers, they often referred to los fujimoristas, members of congress and other national offices that belong to the Fuerza Popular political party led by Keiko Fujimori, daughter of right-wing former President Alberto Fujimori. At the time of the interviews, los fujimoristas made up almost half of Congress, making Fuerza Popular the largest political party by far.[18] Sutton and Borland describe the “Economic/Social Justice” frame they saw in the Encuentros as “a frame that can ‘speak to’ leftist political parties and mixed-gender popular organizations concerned with class inequalities and social injustice for whom gender discrimination is not an explicit or main preoccupation.”[16]

It is possible that the activists in this study were thinking more of the conservative policymakers when they presented their framing; in this case, using the Economic frame may not have seemed practical to them.

A clear example of how certain topics may resonate with general audiences in Peru versus policymaker audiences is the topic of abortion in cases of sexual assault. Many Peruvian activists are advocating that pregnancy resulting from rape be considered as grounds for legal abortion. A slightly higher percentage of Peruvians supports the decriminalisation of abortion in cases of rape than oppose it (48.8% vs. 46.2%).[19] However, Congress, at the same time, has avoided passing any bill that would decriminalise abortion for this reason. If the framing of abortion legalisation in cases of rape resonated with policymakers the same way it did with ordinary citizens, we might expect to see more congressional support for bills that allow rape as a legal ground for abortion. However, the last time a bill to legalise abortion in cases of rape was considered was in 2015 with the Congressional Constitution and Regulation Commission in the Peruvian Congress. This bill never even reached the unicameral floor for a vote because four out of five members who voted on the committee rejected the opportunity to bring it to the full Congress for a vote.[20] This example does not illustrate which frames resonate better with policymakers; it only highlights a concrete case that what may be popular with Peruvian citizens is not necessarily popular with those in Congress.

In sum, the significance of this work is to demonstrate that the framing of abortion, or any other highly stigmatised issue, may have a tendency to be tailored to specific audiences. How effective such frames are in generating needed conversations and, ultimately, in changing abortion policy is an important topic for further research.

Limitations and opportunities for future research

The 10 participants in this study are not representative of the entirety of Peru or even Lima. Many potential activists could not be identified for interviews because they do not belong to a visible professional network that advocates for abortion rights. Future research should identify a range of activists working outside of Lima as well as activists who are not visibly in the forefront. Notably missing from the research are the perspectives of policymakers. Better understanding the frames that resonate with them is important if legislative advances are to be made toward greater access to safe abortion.